Addiction and recovery are serious business. Lives are literally at stake.
It’s a world where words and the concepts they describe have enormous potential to do good, or harm.
Over time, I’ve developed what I call The Devil’s Dictionary of Recovery Terms. These are words or phrases which I have come to believe do more harm than good.
Ron at the blog An Addict in Our Son’s Bedroom did a great post about the term “hitting bottom” today. Read it here.
Ron says in his post, “For many years through this journey people have counseled us that nothing will actually change until our addict hits bottom.”
Ron goes on to explore the term, and it seems clear to me that he is uncomfortable with the term. We all should be.
He tried to learn from the experts what he should expect about his son “hitting bottom.” The answers he got were “always vague and indeterminate,” he says. “Bottom is different for every person,” they told him.
I think Ron, and thousands of other parents, have been given bad counsel. A LOT can change without an opiate dependent person “hitting bottom.”
In a familiar pattern with words and phrases that make it into The Devil’s Dictionary of Recovery Terms, the devilment starts with a kernel of truth: discomfort is motivating.
When you put your hand onto a hot burner, the pain motivates you to remove your hand from the fire. Great.
So the pain of “hitting bottom” should motivate the opiate dependent person to stop using opiates. And to some extent it does.
Here’s the problem:
1. An opiate dependent person does not have full exercise of their free will. Their free will is compromised.
To continue with the hand in the fire metaphor, the opiate dependent person does not have full control over their hand.
They can’t just pull it out of the fire. They need help to get it out of the fire.
They would pull their hand out of the fire on their own if they could, of course.
So just sitting idly by waiting and waiting for them to pull their hand out of the fire while the pain and harm gets worse and worse is just stupid and cruel.
2. Opiate dependence is powerful enough and the opiate dependent person’s free will is compromised enough, that waiting for the person to “hit bottom” can mean the person goes on to experience HIV infection, Hepatitis C infection, unemployment, homelessness, incarceration, loss of child custody, loss of family relationships, risk of violence, or worse.
They might die of a fatal drug overdose before they ever have the fabled opportunity for recovery that hitting bottom is said to bestow.
And let’s not forget the collateral damage to families and communities.
You can’t wait for an opiate dependent person to “hit bottom.” The price is too high.
What drug treatment program would be granted funding if they explained that their program would effectively treat opiate dependence, but it would first require subjecting the client to that list of horrors?
3. Opiate dependence is powerful enough and the opiate dependent person’s free will is compromised enough that most of the time this kind of extreme suffering/harm/damage is not sufficient to create the conditions necessary for successful recovery.
This means that the suffering/harm/damage was unnecessary, because it didn’t work.
4. Most of the time this kind of extreme pain/harm/damage is not necessary to create the conditions necessary for successful recovery.
Even if all that pain does create some motivation to change, less destructive and more effective methods are available to set the stage for recovery.
5. The concept excuses drug treatment professionals from taking responsibility for their own failures.
They don’t have to make the effort to improve their treatment interventions. They don’t have to acknowledge or remedy their own inability to effectively engage, retain and treat clients.
It’s an excuse to say that a client doesn’t want treatment or left treatment early because they haven’t hit bottom. No Mr. Treatment Provider, you haven’t developed the skill or program design necessary to engage and retain the client in treatment.
It’s an excuse to say that a client relapsed during or after treatment because they haven’t hit bottom. No Ms. Treatment Provider, you haven’t developed the skill or the program design necessary to adequately stabilize that client in recovery.
Treatments fail clients, clients don’t fail treatments.
6. The concept implies that it is a good thing for people who are opiate dependent to experience pain, suffering and serious harm. It says that all that harm is necessary to get to recovery.
The concept excuses those who sit idly by and do nothing to prevent suffering.
It gives permission to politicians, treatment providers, probation officers, judges and others to pile on the pain and suffering.
Consider the ER doctor who refuses to use anesthetic to drain an abscess. Or the jail that refuses to provide medical support for opiate withdrawal.
It’s a devil’s delight.
The concept of “hitting bottom” is recovery folklore –nothing more. There is no science to back it up.
I have never seen a scientific research study that proved that an opiate dependent person has to “hit bottom” before they can change.
More than 10 years of experience helping people who inject opiates transition from use to recovery tells me they do not have to hit anything like a “bottom” to achieve recovery.
The sad thing is people living with opiate dependence often do experience extreme suffering and harm. It just doesn’t result in recovery.
And sadder still, recovery was available all along without the need for all that suffering and destruction.
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Thank you, Tom. This makes complete sense to me. With heroin, waiting for the addict to “hit bottom” seems like hoping they get better before they die. I’ve always believed its not the only way to recovery but it seems to be the common philosophy.
Thank you for delving deeper into what I really feel is a complete misuse of a term. In fact I feel it is actually destructive as you describe.
I know 2 people with their stories of drug usage and their “bottom”. 1st person, quit when his child was born. He got a girl pregnant, married her and when he saw that tiny baby he admits that was the stimulus that ended his heroin addiction. Been clean for 5 years. 2nd person, quit when he realized that he had spent 5 years using drugs and there was no single event, he said he just realized his life was going nowhere. Been clean for 25 years.
Neither of these sound like the traditional “bottom”. They just sound like they had a “profound experience” that changed their life. I’m sure there was at times a measure of pain associated with their usage but neither of them said the pain was what caused their change. The experience changed the person not the pain, a profound recognition that their life needed to change an they had to take responsibility to do change it.
Of course there will be people testify to how bad it got and that pain caused them to change. Even with that I still assert that in the midst of their pain they had a profound experience. Most of the people that have told me about their “bottom” and the pain one thing I did observe it was not a single incident of pain. It was not the first time they experienced that pain. It was just the first time they actually recognized the hopelessness of the situation and they had a profound moment.
Ron, I think the way “hitting bottom” and the profound experience may fit into the recovery picture is that they describe a transition of focus.
The stages of change theory of behavior change points out that people need to move from pre-contemplation (lack of sufficient awareness and focus on the need to change) to contemplation (sufficient awareness and focus on the need to change) as a precursor to any actual shift in behavior.
Pain can precipitate this shift. So can a profound experience. So can an intervention. So can counseling, especially using motivational interviewing techniques.
It’s a romantic and beautiful thought that the look in a mother’s eyes, or holding your newborn child in your arms for the first time would be enough to magically wipe away addiction. But the truth is it can at best create a strong desire for change.
If the other conditions for behavior change are also in place, recovery may begin in that moment and continue uninterrupted from that point forward.
But if the other conditions for behavior change are not in place, a person who feels the power of the profound experience deeply and sincerely will not experience instant and perfect recovery from that moment forward.
It’s worth noticing how many opiate dependent people already have a strong desire to change.
Many opiate dependent people who are supposedly “in denial” or “need to hit bottom” are already beyond the need for a shift in focus. They already have a desire for change.
But the shift from pre-contemplation to contemplation is often not enough to ensure a change in behavior. It is just a necessary first step.
Other factors have to be addressed too. The person has to see a path to recovery, and have some sense that if they follow the path they will succeed. Any barriers to recovery have to be identified and removed.
Some people will realize the need for change, identify a path to recovery, and follow that path successfully. It may seem like all it took was getting to the point where they “felt” the need for change, or “wanted it bad enough.”
But other people will feel the need to change with the same intensity, but be blocked by barriers to recovery. They often need support in overcoming these barriers.
Over 90 percent of the people who use the syringe exchange program at my workplace (part of comprehensive approach to helping people transition from current injection drug use to recovery) have already identified that their use is problematic.
Their opiate use has long since passed from recreation or experimentation to nightmare.
Most have tried repeatedly to stop using. Most have detoxed repeatedly. Many have been to residential treatment multiple times.
The problem is they have not yet found a path to sustainable recovery that has worked for them. And many have lost the sense that recovery is possible for them.
Some are gathering strength to try again.
This is why hitting bottom is a destructive concept. Because it isn’t necessary for recovery, and it often isn’t enough for recovery.
Yet it is presented by many people who should know better as something that is both necessary and sufficient for recovery to begin.
Even worse, it is often presented as the recovery itself. It is presented as necessary and enough to instantly and permanently end opiate use by an opiate dependent person.
There is another thing that bothers me about the hitting bottom idea. It often damages the opiate dependent person’s sense of self-efficacy (sense that they can succeed) and self-esteem.
It leaves them with the feeling that they are so depraved and beyond hope that even losing custody of their child, or going to jail, or surviving an overdose is not enough to “make” them stop using.
That is a horrible feeling. And the family members and other people around them are left with the same horrible feeling.
The reality is not that they are depraved or beyond hope. Or that the really bad thing wasn’t bad enough. It’s just that experiencing really bad things is not enough to enable them to change.
good morning, Tom. I wanted to say that I read the most recent entry and I will return this evening, when I have a little more time. You certainly have written a lot of food for thought.
I spent yesterday with my son, and we had long talks. While I fought the idea of methadone just being a band aid– I feel as though my son is the person I once knew, again. I’ll be back.
What a great resource!
this article is very informative. i just joined this website. i cant agree more with your article. i am in a bind, myself. i have an opiate dependancy due to real pain. hoping i find a solution. my back is very messed up, financial strain etc…i have a psychologist who sounds alot like you do so far in that his approach is the why do you use and how can i help you make it easier for you to change. i am prescribed medicine like most, but teeter on a blade on addiction and using as directed. i would ultimately like the pain to stop. narcotics are the only thing that makes me normal. i cant sleep even due to pain. what then? tried so many different approaches but nothing works. not even a counselor counting pills. i so want the madness to stop but i cant take the pain
Tom, thank you for putting into words what I knew to be true at a gut level all along. Bless you for your insight and wisdom! Your article should be sent to every rehab in the country. Yeah, it’s THAT good!!!
Wow, thanks Suz!
Tom, I hope you rec’d. the email I sent regarding posting this article of yours with credit being given to you and your website. This is too good to keep a secret from the hurting family members of addicts. This is gold!
Depending on their length of use, drug of choice, and other health issues, so many addicts are incredibly decompensated in their ability to make rational decisions concerning tapering and withdrawal. Too many family members have been inundated by “black and white” thinking that their approach has got to receive the 12-step stamp of approval or it’s flat out “enabling” and thus should be discarded as faulty. That either/or thinking stymies potential problem-solving approaches.
One size doesn’t fit all addicts, nor does a singular approach only fit just one addict for life. Addiction recovery is recursive in nature, and there needs to be flexibility to reach the addict at his point of need and especially at his greatest point of need.
Bottom-only approaches can be deadly. There seems to justifiably be a right and proper place for various harm-reduction approaches.
I’m so thankful I found this site!
I did get your email Suz, and you are welcome to share the post along with a link back to Recovery Helpdesk. Thanks again for the compliments!
I agree 100 percent with the rest of your comment, and you put it really well….I made need to quote you!